Appointment Reminder Authorization Form
Please select the ways you would like to get reminders:
I authorize the Healthcare Facility to send me appointment reminders via email that is stated below.
I authorize the Healthcare Facility to send me appointment reminders via text message to phone number that is stated below. I understand that text message service is free of charge.
I authorize the Healthcare Facility to send me appointment reminders via voice message. If I cannot answer the phone, permission to leave message to the person who answer or to answering machine is given to the Healthcare Facility.
The Healthcare Facility can contact with me about rescheduling or confirming existing appointments.
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
I am over 18 years old.
Yes
No
Parent/Legal Guardian Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Signature
Parent/Legal Guardian Signature
Submit
Should be Empty: